MRI for Pelvic Pain During Sexual Intercourse

Initial Imaging Approach

The American College of Radiology recommends transvaginal and transabdominal ultrasound with Doppler imaging as the first-line imaging modalities for evaluating pelvic pain during sexual intercourse, providing complementary information 1, 2
Ultrasound is widely regarded as the initial imaging study of choice for pelvic pain, with limited high-quality evidence specifically supporting its use for pain during intercourse 1
Color and spectral Doppler are considered standard components of pelvic sonography to evaluate internal vascularity and distinguish cysts from soft tissue 1, 2

MRI should be considered as a second-line imaging study when ultrasound findings are inconclusive, deep pelvic endometriosis is suspected, or further characterization of abnormalities is needed 1, 3, 4
MRI is also recommended when pelvic floor muscular anatomy and function need assessment 1

The American College of Radiology recommends MRI pelvis with diffusion-weighted imaging (DWI) sequences as the most appropriate protocol 4, 5
The protocol should include diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) mapping 4, 5

MRI has excellent diagnostic performance for deep pelvic endometriosis with sensitivity of 90.3%, specificity of 91%, and accuracy of 90.8% 4
MRI can identify obliteration of fat planes and the pouch of Douglas in deep pelvic endometriosis 4
MRI enables accurate depiction of pelvic floor muscular anatomy, integrity, and function, particularly useful for assessment of muscular hypertonicity in chronic pelvic pain syndromes 1

When DWI is added to MRI protocols for evaluating certain conditions, diagnostic accuracy increases significantly (from 69.6% to 98.6%) 4

The American College of Radiology recommends that MRI should not be used as the initial or primary imaging examination when physical examination is normal 1
The correlation between anatomic abnormalities and symptoms can be weak, and anatomic abnormalities may actually be caused by underlying functional disorders 3

Ordering MRI without first performing ultrasound evaluation is a common pitfall to avoid 1, 3
Failing to include DWI sequences, which significantly improve diagnostic accuracy, is another common pitfall to avoid 4, 5
Attributing symptoms solely to incidental findings without comprehensive clinical correlation is a pitfall to avoid 3
Proceeding to surgical intervention based on imaging findings alone without a rigorous trial of conservative therapy is a pitfall to avoid 3